What do we want? Common purpose: ONE BED, ONE OUTCOME

What do we want? Common purpose: ONE BED, ONE OUTCOME

What do we want? Common Vision: Develop a sustainable, high quality New Care Model for people in community-beds and receiving home-based care services across Gateshead.

What do we want? Change Idea: Develop a New Care Model for enhancing healthcare within community beds (including homebased services) with a new outcome-based contracting and payment system that supports the development of a Provider Alliance Network (PAN) delivery vehicle.

Gateshead - New Model Not about care homes (in isolation) About health and social care integration Cohort - Frailty spectrum A new model for: COMMUNITY BEDS and HOME-BASED CARE

Where we have came from! CARE HOME PROGRAMME 206, 000 population 9% increase in people aged 85 years of age by 2030 Over 1500 beds (community) Started 2010 (enhanced Primary Care) 14.5% reduction in non-elective admissions (baseline 11/12)

Why do we need to improve? Value Proposition DO NOTHING! By 2020: Number of care home beds = 3098 (1500 currently) Cost to health = 3.1m each year By implementing the New Care Model we expect to be able to save 4.1m per year (health only)

If nothing is done differently. This equates to an additional 585 beds (see chart below).

Where we want to get to!

3 Year Plan Gateshead Vanguard Care Homes Project Strategic Delivery Plan 2015-2019 16/17 Year 2 Health care alignment only A Primary Care Led Organisation with associated Community and Acute care alliances delivering contract to care home residents (approx. 1500 people) 17/18 Year 3 Health + public sector alignment A larger Primary Care Led Organisation that s sees wider alliances with community staff across health and social care contracted to deliver care to people in care homes, short-stay community beds and intermediate and reablement services (approx. 15, 000 people) 18/19 Year 4 Health + public sector and private sector alignment established The Primary Care Led Organisation will start to work collaboratively with cocommissioners to explore further alliances with the private sector and contracted to deliver care to all people in long/short stay community beds, intermediate/reablement services and home-based services (approx. 17,000 people)

Case Management Long-stay beds (Care-homes) OUTCOME-BASED CONTRACT + PAYMENTS Short-stay beds (intermediate/reablement beds) CO-COMMISSIONING Home-based care (intermediate / reablement / domiciliary care) Care and Support Planning PROVIDER ALLIANCE NETWORK

How do we get there!

5. Involvement, engagement and communication 6. Workforce Work Streams The programme will be co-designed and implemented through our Work Streams overseen by the Vanguard Core Team. 1. Pathway of Care 2. Commissioning, Contract, Payment 3. Outcomes 4. Evaluation and monitoring VANGUARD CORE TEAM

Involvement, Engagement + Communication

Involvement, Engagement, Communications and outcomes Successful running of 2 cohorts of self-care advocates 18 volunteers now supporting the future development and engagement Celebration event held for first cohort - self-care wheel Care Home Champions group established specific what s App group set up Completed a Heaven and Hell exercise with the care home champions which is now being shared with the integrating provision and commissioning group Engagement to date report completed Strong links with voluntary, community sector organisations Tyne and Wear Sight Service, Age UK, Alzheimer s Society, Equal arts, Jewish Community and Healthwatch Outcomes framework developed that is specific to older people I Statements

SOCIAL INTERACTION/ MEANINGFUL ACTIVITIES/PRIVACY REASSURANCE/ DIGNITY & COMPASSION/ CONFIDENCE MAINTAINING INDEPENDENCE FEELING OF SAFETY FRIENDSHIPS IMPORTANT COMPONENTS OF CARE & WELLBEING FOR THOSE AGED 65 AND OVER COMPETENT STAFF COMMUNICATION/ UP TO DATE INFORMATION/ CONSISTENCY INVOLVED/CHOICE/ EMPOWERED PERSON CENTRED CARE FEELING AT HOME

Pathway of Care (PoC)

Care Pathway Areas of Focus

Pathway of Care (POC) Approach Collect intelligence/learn Experiment/Evaluate Lead/Influence Providing tools Influencing workforce development Making recommendations for contracting

Enhanced Primary Care Care Home Ward Rounds Virtual Ward MDT Clinical Audits Care Home medicines waste/delayed Transfers of Care Care home ward rounds model/older Person Specialist Nurse case loads Dementia diagnosis in the GP record compared to the Care Homes own record Intermediate care residential unit and winter beds audit

Ward Round : Virtual MDT

TECS Strong links and close collaboration with regional IT and technology developments e.g. regional digital road map and Great North Care Record Tablets purchased to support the delivery of care - rolling out bespoke care home NEWS, Hydr8 and falls apps Development of point of care testing in care homes e.g. UTI Transfer of Care bag has been developed (in line with Sutton s Red Bag) 10 expressions of interest received from Care Homes wishing to be involved in phase 1 of roll out + Trusted Assessor Model

Dementia Diagnosis - bespoke pathway Culture and care delivery - dementia is considered normal Transition of care - enhancing and streamlining the admission process moving in to permanent care

Nutrition & Hydration Dedicated dietetics support team to care homes for a food first approach Theory to support UTI point of care testing Normal Ageing Challenges

End of Life Care Delivery - aligned MacMillan nurses with each home Data - baseline of preferred place Planning - end of life discussions before end of life Primary Care - audit of practice of palliative care meetings and upkeep of register

Responsive Care Hospital alternatives Intermediate System - operational groups established for the review of intermediate care in Gateshead and Newcastle IV administration at home: x2 new pathways

Workforce Workforce competency framework A practice educator role Trusted assessor model in development 6 GP s have accessed the BGS Diploma in Geriatric Medicine 2 Specialist Nurses have completed the Nurse Fellowship For Older People Queen Elizabeth Hospital Gateshead - Acute Frailty Network (collaboratively develop acute services for frail older people e.g. interface teams) Active involvement of the CH leadership community of practice events Falls prevention training pilot for care home staff linking to post fall escalation protocol for care home staff

Commissioning, Contracting, Payment Regular LA, CQC and CCG commissioning discussions established monthly Statement of Intent for Integration Gateshead Care Partnership (local acute trust, GP Provider and LA)

Success to Date

Our Measures Reduction in avoidable hospital admissions Increased number of patients with EHCP Reduction in outpatient appointments Increased dementia diagnosis Reduced antipsychotic prescribing Reduced admissions for dehydration related UTI Reduction in nutritional supplement prescribing Increase in preferred place of death Reduction in 111 calls from care homes Increasing intravenous medication administration Increase in 999 see, treat & discharge

Metrics: Task and Finish Groups

Evaluation Commissioned: Regional evaluation (commonalities) POC local evaluation PAN local evaluation NEWS/Hydrate/Transfer of Care evaluations

THE FUTURE

Embedding the work! New Model of Care Population health - MCP/PACS Out of Hospital Care setting GP, Community Services, Social Care, Third + Voluntary Sector Long Term Conditions Care Pathways Pathways STP alignment (role) Learning + sharing + at scale opportunities

Stories This is the link to Annie s story Enhanced Health in care homes (personal story) https://www.youtube.com/watch?v=7vvxjatj6m This is the link to the Virtual Ward https://www.dropbox.com/s/6xwvuf0ebgmu ayz/nhs%20master%20.mov?dl=0